Color Myths:
"Peach stimulates the appetite, so all dining rooms should be
peach."

"Old people can't see blue and green, therefore only use warm
colors."

The amount of advice being given on colors for
older people in general and older individuals with dementia in particular
is rapidly growing. Questions about color-what color care facilities
should be painted or decorated in-are common at conferences that
address design issues for dementia. Unfortunately, like the comments
above, most of this advice has virtually no basis in any empirical
or even systematically gathered evidence. This article will explore
some basic issues about color and its application, summarize what
is known about color perception and impact on behavior or mood,
and provide some guidelines for color application in dementia care
settings.

What you need to know about color
There are two main components that impact how we perceive color.
The first is the pigments used on the surfaces we see-the walls,
the floor, the table surface, everything in our visual field that
we look at. The second is the lighting that is used to provide the
illumination which enables our eyes to see these objects. It is
important to consider both aspects when dealing with color within
the environment. There have been whole books devoted to color theory,
so what follows is a very short and basic introduction to color
issues.

Color as pigment
Most of us remember mixing paints together as children. The more
colors you put together, the muddier and closer to gray the colors
got. Pigment colors (as opposed to light, which we'll get to in
a minute) are called subtractive, in that when you mixed them together,
the resultant colors are closer to black, which is the "absence"
of color. There are three primary colors: red, blue and yellow,
and three secondary colors: green, orange and violet. They are often
seen in a color wheel. Colors vary along three dimensions. Hue is
what we typically refer to as color, and is made up of one or more
of the primary and secondary colors. Value is the lightness or darkness
of the color. A lighter value is called a tint, which is a color
with white added, and a darker value, or shade, is the color with
black added. So pink is a tint of red and burgundy is a shade of
red. The third dimension is chroma, or the brilliance of the color.
The primary colors, in their pure form, have the brightest chroma
and are the most brilliant. When other colors (such as another primary
color or a secondary color) are mixed with a "pure" color,
the chroma decreases. Mixing a color from the opposite side of the
color wheel (e.g. mixing red with green) produces the lowest intensity
or chroma of red, and the color appears neutral gray. Additionally,
colors are often referred to as being warm (reds, oranges and yellows)
or cool (blues, violets and greens).

Together these three dimensions make up what we
typically call "colors." By varying colors along these
three dimensions, we can create infinite variety within our world.
These variations, when put together, create what is called contrasts.
Just imagine what the world would be like if everything were the
same hue, value and chroma-if everything were the same color. It
would be virtually impossible to "see" anything in the
world, because everything would look the same. There would be no
difference in the color of the paper you are reading from and the
table it is sitting on-there would actually be no printing on the
page either, and no shading from light sources to tell you where
there were edges on objects. But because colors vary across these
three dimensions, there are a number of different contrasts. Itten
(1970), an early developer of color theory, described seven contrasts.
Only the three that are most relevant for our purposes will be reviewed
here.

Contrast of hue is when two different hues (such
as red and blue) are placed next to each other. Contrast of light
and dark occurs when different tints and shades are placed next
to each other. Contrast of cold and warm occurs when colors of different
temperatures, such as orange (which is warm) and blue (which is
cool) are placed next to each other. As we will see, appropriate
use of contrast is probably more important in interior design for
people with dementia than specific colors.

Color as Light
Light is essential to perception-without light, we would not see
anything. And like everything that surrounds us in the environment,
light is made up of colors as well (the same six colors as pigments,
plus indigo). The way we perceive color is actually a combination
of the pigment color in the objects, and the colors in the light
that reflect off the objects in our environment. What the eye actually
perceives are the light waves that bounce off objects, and the color
we perceive is the color of light that is not absorbed by objects,
but reflected off of them.

What's important to know about lighting is that
different kinds of light bulbs give off different amount of light
waves in the different colors. So how a color is perceived under
one type of lighting may be very different that how it is perceived
under a different type of light blub. Incandescent and warm white
fluorescent bulbs are very warm and radiate mostly red and yellow
light. These lamps will intensify warm colors and cool colors will
be neutralized. Cool white fluorescent bulbs have more green and
blue, and so cool colors in the environment are intensified.

When selecting colors, it is always best to try
to look at the colors under the same type of lighting as the room
or space the color will eventually be in. In existing environments,
this is relatively easy. In new construction, the lamps and lighting
fixtures may not be installed by the time decisions about color
need to be made. In these cases, determine what type of lamps will
be specified for the project, and either find a place that uses
these lamps to view your colors, or create a mock-up space where
you can install a few lamps of the appropriate type. In generally,
it is best to use lamps that have a color spectrum that is close
to daylight. There are many of these "color corrected"
bulbs on the market. Talk to your lighting designer, or salesperson
where you buy your lamps, and ask for lamps that are close to daylight.

Impact of color across the life-span
Studies involving color and light have been conducted for decades,
even centuries. While there are many disparate results, there are
also come commonalities about color that are worth mentioning. None
of the research reported here was conducted specifically on older
individuals or people with dementia, but there is no evidence that
the impacts would be very different for these individuals. It should
also be noted that the research seldom reports what hues or values
the research is done with. Therefore, it is impossible to know what
"color" was used in the research, and these results should
be applied with some caution.

Blue is a restful color with a calming effect
. Research suggests use of blue (probably tested by painting a room
in various shades of blue) in the physical environment can actually
lower blood pressure. It has also been shown that blue (and green)
rooms are perceived as several degrees cooler than rooms painted
in warm shades (reds and oranges). Blue also increases the apparent
size of a space.

Red increase brain wave activity and can stimulate
the production of adrenalin into the blood stream. It will also
decrease the apparent size of a room, making it look smaller. Red
can also increase the apparent temperature of a room, and thus may
be useful in rooms that are habitually on the cool side.

Green is associated life growth and life, and
is the most restful of colors. Green reduces central nervous system
activity and helps people feel calm. Like other cool colors, it
makes rooms appear larger.

Violet does not appear to have consistent affects
on either mood or the nervous system. This may be because it is
a combination of red and blue, which are at opposite ends of the
light color spectrum.

Orange is a relatively new color (having appeared
in European language only in the tenth or eleventh century). It
is closely associated with red, being a warm color, and shares some
similar properties. It is also, however, an "earth-base"
color, and like green produces associations with nature and natural
environments.

Yellow is a highly visible color and thus is often
used to carry important messages (road signage). It makes rooms
appear larger, and thus is good for small rooms where you want a
restful atmosphere.

Color and the aging eye
As people age, there are a number of changes that occur which affect
both vision and color perception. This next section will only deal
with the changes in vision and perception as they relate to color
perception. Of course, many people, particularly men, are considered
"color blind" even at a young age. Most typically, these
individuals have a hard time distinguishing between reds and greens.
Changes in vision and color perception typically begin to occur
in the 20's and continue to deteriorate through the end of life.
Beyond changes in ability to focus (being near or far-sighted, which
in and of itself does not affect color perception), color perception
or discrimination diminishes. There is also a thickening and yellowing
of the lens of the eye, which is similar to viewing the world through
a pale yellow film (approximately the color of ginger ale). This
makes it harder to differentiate between colors in the green and
blue shades (because green is a combination of blue and yellow).
This yellowing also "absorbs" more of the blue light entering
the eye (up to 75%), which means things in the environment look
much more yellow to an older person than to a younger individual
(Baucom, 1996).

There has been some research on color preference,
both across the life span and for people over 65. Results are generally
very consistent, at least for the top three preference choices,
with blue, red and green being most preferred, in that order (Wijk
2001; Reeves, 1985).

Changes with Dementia
There has been little research specifically on color perception
in dementia, although there are a few articles that have been recently
published. Rizzo and colleagues (2000) compared 43 individuals with
mild Alzheimer's Disease (AD) and 22 people without dementia. Basic
visual functioning (acuity and motion direction discrimination)
was similar for both groups, but the people with dementia scored
significantly worse on tests of contrast sensitivity, visual attention
and color. Wijk and colleagues (1999, 2001) conducted several tests,
and found, not surprisingly, a marked decrease in color naming ability
in individuals with dementia when compared with cognitively-intact
elderly. Unlike Rizzo's research, there was no difference between
the groups on color perception (being able to pick out which color
was different when presented three color swatches). Both groups
found it easier to distinguish between colors in the red/yellow
range, and harder to distinguish colors in the blue/green range.
The lightness of the color (tint and shade) was an important factor
in being able to discriminate between colors). Color preference
ratings were similar for people with dementia as for the comparison
group: that is, blue, red and green were most preferred, in that
order.

Color application
The data above might suggest that all environments should be primarily
blue, red or green. However, it's important to recognize that color
preference studies are typically done with small chips of colored
paper, which is very different than seeing the color applied to
one or more wall surfaces. Nor do these studies explore preferences
related to value or chroma, only hue, although Wijk (2001) did find
that value (lightness) had a significant impact on color discrimination.
Complex issues such as pattern or amount of coverage of color vs.
background have not even been considered within the research conducted
to date. Despite these limitations, there are still some basic color
principles that can be reasonably applied when creating settings
for people with dementia.

Principle #1: Emphasize what's important. Within
any setting, there are some elements that carry important information,
such as orientation cues, or views to interesting vistas or activity
areas. Pay close attention to those elements that have the potential
to provide useful information to the cognitively impaired individual,
and give these more emphasis with brighter colors (using hue, value
and chroma), higher contrast with the background, and more light.

- Signage that is meant to be read/interpreted by the person with
dementia should be highlighted in this manner, while signage for
staff or visitors should be given less emphasis (hues and values
that are more similar to the background).

- Provide high hue and value contrast at the edges of stairs or
level changes so they are easy for people to see, which can minimize
falls.

- When using colors as part of an orientation cue system, remember
that older individuals have a harder time distinguishing between
colors in the cooler range-blues and greens particularly. Also,
many individuals are color blind and have a hard time distinguishing
between red and green. Therefore, color is not probably appropriate
as the sole differentiating feature between different elements-they
should vary in other design features as well. Varying the value
of colors (the lightness or darkness) by at least 2 levels on a
10 level gray scale will enable most people will be able to differentiate
between the colors.

Principle #2: De-emphasize what's not important. Although this seems
like a restatement of principle #1, designers often use color and
pattern in ways that draw attention to elements that should be in
the background of the visual field. People with dementia struggle
to make sense of their environments, and should not have their attention
unnecessarily drawn to elements that do not convey meaningful information.

- Floors are an important functional element, not just a surface
to be decorated. Avoid high contrasting, bold patterns. Avoid high
contrasting borders within rooms or in hallways. Subtle color changes,
such as heathering in the pattern is appropriate. Color change at
doorways or transitions between rooms is appropriate, although if
the change is distinctive (high color or value contrast), it's best
to make sure there are handrails for people to hold onto while making
the transition. Changes in hue and value often appear to be a change
in level which people try to step over.

- If you don't want residents "hanging around" the staff
work spaces, make the colors blend in with the background. Remember
however, that it is probably the presence of staff that draws residents
to these areas more than the color of the space.

Principle #3: Compensate for known visual deficits. Older people
requires three times the amount of light to see as well as younger
people, but are more sensitive to glare. People with dementia have
impaired contrast perception, which makes it harder to see the edges
of objects, particularly when the foreground (object) and background
are similar color and value. This is particularly important when
designing to support functional independence.

- Chair seats should contrast with the floor to people can see where
the edge of the chair is.

- Sink basins should contrast with the surrounding counter/vanity
top.

- Toilets (or toilet seats) should contrast with both the floor
and surrounding walls to make them more visible.

- Table settings should provide high contrast between the plates
(usually white or pale colored) and the table/tablecloth/placemat
(dark color).

- Colors that are a mix of hues from the opposite side of the color
wheel (such as red and green, or yellow and blue) will appear particularly
muddy, and thus be less attractive, to older individuals whose lens
is yellowed.

Principle #4: Apply color according to known principles. People
with dementia may have some unique needs, but they are still people,
and no research has yet suggested they respond differently emotionally/visually
to colors than the general population. Therefore, the established
physiological impacts described in the section on Impact of Color
Across the Life Span are probably appropriate for this population.

- Rooms that are habitually too warm that are decorated in cool
colors (blues and violets) will be perceived as cooler. Conversely,
decorating a cool room with warm colors will make it appear to be
warmer than it actually is.

- If space is at a premium and rooms and small and tight, using
cooler colors will make them appear to be slightly larger.

- If you want to space to be an "active" place, use warm
colors, particularly red, which is physiologically stimulating.

Concluding Thoughts
There is a need for more systematic research on the behavioral/emotional
impact of colors on people with dementia, particularly studies that
look at color as it is applied in the environment, not just on small
swatches of paper. There are some enticing possibilities about being
able to create spaces that encourage more activity and participation,
or places that are calmer and more restful, but the lack of research
hinders designers from being able to apply colors with confidence.
There is better knowledge about perception and contrasts, which
can support the creation of environments that enhance independent
functioning. Clearly, if one can't see a white toilet against white
floor and walls, one will have a hard time maintaining continence.
Judicious use of contrast, using the hue, value and chroma dimensions
of color, should be given careful consideration when creating spaces
for people with dementia.